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Whitesell RT, Brunner JF, Collins HR, Sheafor DH. Qualitative and quantitative spermatic cord abnormalities at CT predict symptomatic scrotal pathology. Abdom Radiol (NY) 2024; 49:2049-2059. [PMID: 38517545 PMCID: PMC11213788 DOI: 10.1007/s00261-024-04251-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2023] [Revised: 02/10/2024] [Accepted: 02/12/2024] [Indexed: 03/24/2024]
Abstract
PURPOSE To evaluate quantitative and qualitative spermatic cord CT abnormalities and presence of unilateral or bilateral symptomatic scrotal pathology (SSP) at ultrasound. METHODS This retrospective study included 122 male patients (mean age 47.8 years) undergoing scrotal ultrasound within 24 h of contrast-enhanced CT (n = 85), non-contrast CT (NECT, n = 32) or CT-Urogram (n = 5). CECT quantitative analysis assessed differential cord enhancement using maximum Hounsfield unit measurements. Three fellowship trained body radiologists independently assessed qualitative cord abnormalities for both CECT and NECT. Qualitative and quantitative findings were compared with the presence of SSP. Reader performance, interobserver agreement and reader confidence were assessed for NECT and CECT. Quantitative cutoff points were identified which maximized accuracy, specificity, negative predictive value, and other measures. RESULTS SSP was present in 36/122 patients (29.5%). Positive cases were unilateral in 30 (83.3%) and bilateral in 6 (16.6%). At quantitative assessment, 25% differential cord enhancement had the highest diagnostic accuracy (88.9%), with 90.5% positive predictive value, 88.4% negative predictive value, 96.8% specificity, and 70.4% sensitivity. At qualitative evaluation, CECT reader performance was excellent (aggregate AUC = 0.86; P < .001); NECT was poorly discriminatory, although remained significant (aggregate AUC = 0.67; P = .002). Readers had significantly higher confidence levels with CECT (P < .001). Qualitative inter-observer agreement was high for both CECT and NECT (ICC = 0.981 and 0.963, respectively). CONCLUSION Simple quantitative assessment of differential cord enhancement is highly accurate and specific for SSP at CECT. Qualitative abnormalities at CECT and NECT are also both predictors of SSP, however, CECT significantly out-performs non-contrast exams.
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Affiliation(s)
| | - John F Brunner
- Midwest Radiology, 2355 Highway 36 West, Roseville, MN, USA
| | - Heather R Collins
- Department of Radiology, Medical University of South Carolina, Charleston, SC, USA
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Yadav S, Rawal G, Jeyaraman M. Decision Fatigue in Emergency Medicine: An Exploration of Its Validity. Cureus 2023; 15:e51267. [PMID: 38288179 PMCID: PMC10823191 DOI: 10.7759/cureus.51267] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/29/2023] [Indexed: 01/31/2024] Open
Abstract
Emergency physicians face a relentless stream of complex, high-stakes decisions in a fast-paced and dynamic environment. The concept of decision fatigue, a phenomenon characterized by a decline in the quality of decision-making after a long sequence of choices, has garnered increasing attention within healthcare. Several investigations show that the number and complexity of decisions made during prolonged shifts correlate with increased self-reported fatigue; however, the effect on clinical decision quality is uncertain. Conversely, a subset of studies found no clear relationship between decision fatigue and errors in clinical judgment. Importantly, some researchers argue that decision fatigue may be mitigated by factors such as experience, training, and support systems. This narrative review highlights the existing literature on decision fatigue among emergency physicians and explores whether this concept holds as a valid concern or remains a myth in the context of their practice.
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Affiliation(s)
- Sankalp Yadav
- Medicine, Shri Madan Lal Khurana Chest Clinic, New Delhi, IND
| | - Gautam Rawal
- Respiratory Medical Critical Care, Max Super Speciality Hospital, New Delhi, IND
| | - Madhan Jeyaraman
- Orthopaedics, ACS Medical College and Hospital, Dr. MGR Educational and Research Institute, Chennai, IND
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Al-Arimi AH, Hazra D, Al-Alawi AKA. Impact of Fatigue on Emergency Physicians' Decision-making for Computed Tomographic Scan Requests and Inpatient Referrals: An Observational Study from a Tertiary Care Medical Center of the Sultanate of Oman. Indian J Crit Care Med 2023; 27:620-624. [PMID: 37719345 PMCID: PMC10504659 DOI: 10.5005/jp-journals-10071-24520] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2023] [Accepted: 07/28/2023] [Indexed: 09/19/2023] Open
Abstract
Objective Multiple factors contribute to decision fatigue experienced by emergency physicians (EPs). This study examines the association between decision fatigue and the frequency of computed tomographic (CT) scan requests and inpatient referrals among EPs. Methods This retrospective database analysis was done for 3 months. Scans and inpatient referral requests were coded and analyzed to assess the impact of physician fatigue on decision-making. Subsequently, the outcomes were evaluated. Results The majority of patients (n = 481; 51.1%) had a CT brain request. Among these requests, the morning shift (8:00 a.m.-3:00 p.m.) accounted for the highest number (n = 400; 42.5%), followed by the evening shift (3:00-11:00 p.m.) (n = 345; 36.7%). Approximately one-third of the patients (n = 301; 31.9%) had positive CT scan findings. Statistical analysis comparing the first and the second halves of each shift did not reveal significant variations in the percentage of negative CT results (p-value: 0.093). Inpatient referral was necessary for over half of the patients (n = 1,048; 52.7%), and the majority of these referrals (n = 778; 74.2%) were deemed necessary for treatment under various surgical or medical specialties. There was a statistically significant difference in the proportion of negative inpatient referrals between the first and the second halves of the afternoon shift (p-value < 0.001). Conclusions Fatigue among EPs was observed, leading to more frequent consultations without inpatient admission during the latter half of the afternoon shift. However, the study found no significant impact of decision fatigue on CT scan decision-making. How to cite this article Al-Arimi AH, Hazra D, Al-Alawi AKA. Impact of Fatigue on Emergency Physicians' Decision-making for Computed Tomographic Scan Requests and Inpatient Referrals: An Observational Study from a Tertiary Care Medical Center of the Sultanate of Oman. Indian J Crit Care Med 2023;27(9):620-624.
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Affiliation(s)
- Asma H Al-Arimi
- Emergency Medicine Residency Training Program, Oman Medical Specialty Board, Muscat, Sultanate of Oman
| | - Darpanarayan Hazra
- Department of Emergency Medicine, Sultan Qaboos University Hospital, Muscat, Sultanate of Oman
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Crowder K, Domm E, Lipp R, Robinson O, Vatanpour S, Wang D, Lang E. The multicenter impacts of an emergency physician lead on departmental flow and provider experiences. CAN J EMERG MED 2023; 25:224-232. [PMID: 36790639 DOI: 10.1007/s43678-023-00459-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2022] [Accepted: 01/13/2023] [Indexed: 02/16/2023]
Abstract
INTRODUCTION Emergency department (ED) flow impacts patient safety, quality of care and ED provider satisfaction. Throughput interventions have been shown to improve flow, yet few studies have reported the impact of ED physician leadership roles on patient flow and provider experiences. The study objective was to evaluate the impacts of the emergency physician lead role on ED flow metrics and provider experiences. METHODS Quantitative data about patient flow metrics were collected from ED information systems in two tertiary hospital EDs and analyzed to compare ED length of stay, EMS hallway length of stay, physician initial assessment time, 72-h readmission and left without being seen rates three months before and following emergency physician lead role implementation. ED flow metrics for adult patients at each site were analyzed independently using descriptive and inferential statistics, t tests and multivariable regression analysis. Qualitative data were collected via surveys from ED providers (physicians, nurses, and EMS) about their experiences working with the emergency physician leads and analyzed for themes about emergency physician leads impact. RESULTS The number of ED visits was relatively stable pre-post at the Peter Lougheed Centre (Lougheed) but increased pre-post at the Foothills Medical Centre (Foothills). Post-intervention at Lougheed median ED length of stay decreased by 18 min (p < 0.001) and at Foothills ED length of stay increased by 8 min (p < 0.001). EMS length of stay at Lougheed decreased by 20 min (p < 0.001), and at Foothills length of stay increased by 17 min (p < 0.001). Themes in provider feedback were that emergency physician leads (1) facilitated patient flow, (2) impacted provider workload, and (3) supported patient flow and safety with early assessments, treatments and investigations. CONCLUSION In this study, the emergency physician lead impacted ED flow metrics variably at different sites, but important learnings from provider experiences can guide future emergency physician lead implementation.
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Affiliation(s)
- Kathryn Crowder
- Department of Emergency Medicine, Alberta Health Services, Calgary, AB, Canada. .,University of Calgary Cumming School of Medicine, Calgary, AB, Canada.
| | - Elizabeth Domm
- Faculty of Nursing, University of Regina, Regina, SK, Canada
| | - Rachel Lipp
- University of Calgary Cumming School of Medicine, Calgary, AB, Canada
| | - Owen Robinson
- University of Calgary Cumming School of Medicine, Calgary, AB, Canada
| | - Shabnam Vatanpour
- University of Calgary Cumming School of Medicine, Calgary, AB, Canada
| | - Dongmei Wang
- Department of Emergency Medicine, Alberta Health Services, Calgary, AB, Canada
| | - Eddy Lang
- Department of Emergency Medicine, Alberta Health Services, Calgary, AB, Canada.,University of Calgary Cumming School of Medicine, Calgary, AB, Canada
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Effect of a split-flow physician in triage model on abdominal CT ordering rate and yield. Am J Emerg Med 2020; 46:160-164. [PMID: 33071089 DOI: 10.1016/j.ajem.2020.05.119] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2020] [Revised: 05/19/2020] [Accepted: 05/25/2020] [Indexed: 11/22/2022] Open
Abstract
OBJECTIVE The objective of this study was to compare the rate and clinical yield of computed tomography (CT) imaging between patients presenting with abdominal pain initially seen by a physician in triage (PIT) versus those seen only by physicians working in the main emergency department (ED). METHODS A retrospective study was conducted of all self-arrivals >18 years old presenting to a single ED with abdominal pain. Nine-hundred patients were randomly selected from both the PIT and traditional patient flow groups and rates and yields of CT imaging were compared, both alone and in a model controlling for potential confounders. Predetermined criteria for CT significance included need for admission, consult, or targeted medications. RESULTS The overall rate of CT imaging (unadjusted) did not differ between the PIT and traditional groups, 48.7% (95% CI 45.4-51.9) vs. 45.1% (95% CI 41.8-48.4), respectively (p = .13). The CT yield for patients seen in in the PIT group was also similar to that of the traditional group: 49.1% (95% CI 44.4-53.8) vs. 50.5% (95% CI 45.6-55.4) (p = .68). In the logistic regression model, when controlling for age, gender, ESI-acuity, race and insurance payor, PIT vs. traditional was not a predictor of CT ordering (OR 1.14, 95% CI 0.94-1.38). CONCLUSIONS For patients with abdominal pain, we found no significant differences in rates of CT ordering or CT yield for patients seen in a PIT vs. traditional models, suggesting the increased efficiencies offered by PIT models do not come at the cost of increased or decreased imaging utilization.
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Ullrich M, LaBond V, Britt T, Bishop K, Barber K. Influence of emergency department patient volumes on CT utilization rate of the physician in triage. Am J Emerg Med 2020; 39:11-14. [PMID: 32448774 DOI: 10.1016/j.ajem.2020.04.085] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2020] [Revised: 04/20/2020] [Accepted: 04/24/2020] [Indexed: 10/24/2022] Open
Abstract
BACKGROUND Physician in triage (PIT) has been used as a potential solution to emergency department (ED) overcrowding and to decrease ED length of stay (LOS). This study examined the relationship between computerized tomography (CT) utilization of PIT and ED patient volumes. We hypothesized that despite the pressure on PIT to improve throughput on the busiest days, they will continue to utilize CT at the same rate. METHODS This retrospective chart review evaluated CT ordering patterns of PIT on patients with abdominal pain who presented to the ED over a 6-year period. CT utilization rate was calculated on days with the lowest 5% (LD5) and highest 5% (HD5) volumes based on average yearly volume. CT positive and negative rates were correlated with volume using Chi square analysis. Odds ratio and confidence intervals were calculated for the magnitude of effect difference. RESULTS We found no statistically significant difference in CT utilization rate on HD5 vs LD5 (p = 0.833). There was a statistically significant increase in the rate of negative CT scans on HD5 (p = 0.046) which represented a 17% relative difference. LOS was longer on HD5 (p = 0.013) and when a CT scan was ordered (p < 0.001). CONCLUSION No difference was found in the rate at which the PIT ordered CT scans on high volume vs low volume days. The rate of CT scans without clinically relevant findings did increase slightly on high volume days. LOS was longer on high volume days and when a CT was ordered.
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Affiliation(s)
- Matthew Ullrich
- Ascension Genesys Hospital, One Genesys Parkway, Grand Blanc, MI 48439, United States of America
| | - Virginia LaBond
- Ascension Genesys Hospital, One Genesys Parkway, Grand Blanc, MI 48439, United States of America.
| | - Todd Britt
- Ascension Genesys Hospital, One Genesys Parkway, Grand Blanc, MI 48439, United States of America
| | - Kaitlyn Bishop
- Ascension Genesys Hospital, One Genesys Parkway, Grand Blanc, MI 48439, United States of America
| | - Kimberly Barber
- Ascension Genesys Hospital, One Genesys Parkway, Grand Blanc, MI 48439, United States of America
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Decision fatigue in the Emergency Department: How does emergency physician decision making change over an eight-hour shift? Am J Emerg Med 2020; 38:2506-2510. [PMID: 31937441 DOI: 10.1016/j.ajem.2019.12.020] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2019] [Revised: 12/12/2019] [Accepted: 12/13/2019] [Indexed: 11/21/2022] Open
Abstract
INTRODUCTION We examined emergency physician disposition decisions and computed tomography (CT) ordering as markers of decision fatigue over an eight-hour shift. METHODS Administrative database analysis of patients presenting to an academic, tertiary care, emergency department (ED) over two years. Patients were grouped by the hour of the shift that they were initially assessed by an emergency physician. For each hour, we evaluated the proportions of patients who had CT head, chest, or abdomen, consultations, and consultations not resulting in admission. For patients discharged without consultation, we evaluated return visits within 72 h and ED length-of-stay (LOS). Statistical significance was assessed using random effects regression accounting for clustering by physician. RESULTS We analyzed 87,752 patients and there were no important differences in consultations, consultations not resulting in admission, or return visits in relation to the hour of shift the patient was seen. Rates of CT head and abdomen and ED LOS decreased as the shift progressed. From the first to the last hour, CT head ordering decreased from 15.8% to 12.2% (OR 0.73, 95% CI 0.66-0.80, p < 0.0001), CT abdomen ordering decreased from 9.6% to 7.6% (OR 0.72, 95% CI 0.64-0.80, p < 0.0001), and ED LOS decreased from 5.5 h to 4.9 h (relative difference 0.83, 95% CI 0.81-0.85, p < 0.0001). CONCLUSIONS Emergency physician decisions about patient disposition did not change throughout the shift. The rates of CT head and abdomen and ED LOS decreased as the shift progressed. We did not find evidence of decision fatigue among emergency physicians over an eight-hour shift.
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Repeat CT Performed Within One Month of CT Conducted in the Emergency Department for Abdominal Pain: A Secondary Analysis of Data From a Prospective Multicenter Study. AJR Am J Roentgenol 2018; 212:382-385. [PMID: 30512995 DOI: 10.2214/ajr.18.20060] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
OBJECTIVE The purpose of this study is to determine both the frequency of repeat CT performed within 1 month after a patient visits the emergency department (ED) and undergoes CT evaluation for abdominal pain and the frequency of worsened or new CT-based diagnoses. SUBJECTS AND METHODS Secondary analysis was performed on data collected during a prospective multicenter study. The parent study included patients who underwent CT in the ED for abdominal pain between 2012 and 2014, and these patients constituted the study group of the present analysis. The proportion of patients who underwent (in any setting) repeat abdominal CT within 1 month of the index CT examination was calculated. For each of these patients, results of the index and repeat CT scans were compared by an independent panel and categorized as follows: no change (group 1); same process, improved (group 2); same process, worse (group 3); or different process (group 4). The proportion of patients in groups 1 and 2 versus groups 3 and 4 was calculated, and patient and ED physician characteristics were compared. RESULTS The parent study included 544 patients (246 of whom were men [45%]; mean patient age, 49.4 years). Of those 544 patients, 53 (10%; 95% CI, 7.5-13%) underwent repeat abdominal CT. Patients' CT comparisons were categorized as follows: group 1 for 43% of patients (23/53), group 2 for 26% (14/53), group 3 for 15% (8/53), and group 4 for 15% (8/53). New or worse findings were present in 30% of patients (16/53) (95% CI, 19-44%). When patients with findings in groups 1 and 2 were compared to patients with findings in groups 3 and 4, no significant difference was noted in patient age (p = 0.25) or sex (p = 0.76), the number of days between scans (p = 0.98), and the diagnostic confidence of the ED physician after the index CT scan was obtained (p = 0.33). CONCLUSION Short-term, repeat abdominal CT was performed for 10% of patients who underwent CT in the ED for abdominal pain, and it yielded new or worse findings for 30% of those patients.
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